British Journal of Urology (197% 41, 631-633 0

The Management of Pyocystis following Ileal Conduit Urinary Diversion in Children PETER

s. STEVENS, and

HERBERT

B. ECKSTEIN

Queen Mary's Hospital for Children, Carshalton, Surrey; and The Hospital for Sick Children, Great Orniond Street. London

Infection in the defunctioned bladder occurs in one-fifth (Eckstein and Mohindra, 1970) to onethird (Smith, 1972) of children following ileal conduit urinary diversion. In the management of this distressing problem the clinician has several modes of therapy available and we report the experience in a large series of children undergoing urinary diversion. Patients The records of 113 patients who underwent ileal conduit urinary diversion between 1961 and 1973 were reviewed. All patients had been operated upon by the senior author (H. B. E) or an assistant under his direct supervision. Of this group, 27 (24%) (26 females and 1 male) developed purulent urethral discharge postoperatively. All patients had myelomeningocele with neuropathic bladders .and had had urinary diversion for progressive upper urinary tract deterioration ( 14 patients) incontinence (1 I patients), or uncontrolled urinary infection (1 patient). The age at diversion ranged between 6 months and 11 years, and the initial signs and symptoms of pyocystis were ,evident within 3 months after surgery in all patients. 16 of the patients had been intensively treated or hospitalised for severe urinary infection (i.e. pyrexia, loin pain, leucocytosis) prior to diversion. Techniques and Results

I . All patients were treated initially by repeated bladder irrigation with antiseptic (Hibitane, Noxyflex) or antibiotic (Neomycin, Polymixin) solutions. Treatment usually consisted of washing out the bladder once or twice weekly for a month. 11 patients responded to this regimen, although in most cases the cycle of treatment had to be repeated several times before the infection was finally controlled. 2. 1 1 patients in whom bladder discharge was persistent or rapidly recurring, in spite of frequent irrigations, underwent cystectomy. Surgery was straightforward and uncomplicated and apart from wound drainage, there was negligible postoperative morbidity. Since 1973 there have been 5 additional patients who have failed to respond to conservative management. In these patients, vaginal vesicostomy modifying the procedure originally described by Spence and Allen (1971), was performed using the Payr's intestinal clamp. One blade of the clamp was introduced into the vagina and the other into the urethra for a distance of 5 cm and the clamp was then occluded for 5 min. Following this the crushed urethro-vaginal septum was incised until the index finger could be easily inserted into the bladder. No sutures were used. The vaginal and bladder cavities were packed for 48 hours. There have been no intra-operative or postoperative complications. In all cases, bladder discharge ceased or became negligible within several days and has not recurred. 63 1

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BRITISH JOURNAL OF UROLOGY

Discussion Pyocystis is usually manifested by profuse, malodorous “vaginal” or urethral discharge but on occasion can also cause systemic signs of infection. The incidence is much higher in females, presumably because the short urethra predisposes to ascending infection. It tends to occur more frequently in those children who have had recurrent urinary infection, particularly with Proteus species, prior to diversion (Eckstein and Mohindra, 1970). The response of pyocystis to bladder irrigations is primarily related to how vigorously treatment is carried out. There is reluctance to admit the child to hospital to treat a seemingly trivial infection and, on the other hand, there is difficulty in getting this type of treatment accomplished in the home or clinic. The haphazard treatment that usually results explains, in part, why it is variously reported that 2.8% (Richie, 1974) to 14% (Eckstein and Mohindra, 1970) of patients undergoing diversion will require surgery for troublesome persistent discharge. An obvious solution to prevent pyocystis is to perform cystectomy at the time of urinary diversion. This has, however, the disadvantage of prolonging a major operation, with attendant increased morbidity and blood loss in children, many of whom are already in serious difficulty with compromised renal function. In addition, as only a minority of children undergoing diversion will develop pyocystis, it seems unwise to perform concomitant cystectomy on every patient. Lastly, cystectomy at the time of diversion makes the operation irreversible in terms of future lower urinary tract reconstruction. Delayed cystectomy, after failure of medical treatment has long been used in cases of pyocystis. In general the operation presents no difficulty, but it is a major procedure requiring prolonged general anaesthesia. Discharge from hospital is often delayed due to purulent drainage from the pelvic drain and blood transfusion is often required in the young child. In 1971 Spence and Allen described their experience in the use of vaginal vesicostomy in treating women with pyocystis. It proved difficult to adapt their procedure to the young child because the confined space of the vagina made it difficult to visualise the vaginal septum and suture the edges of the vesicostomy. The Payr’s intestinal clamp is ideally suited because its shape conforms to the operative field and its wide crushing blades provide adequate haemostasis without need of suturing. The operation can be easily performed in less than 10 min under light anaesthesia and blood loss is negligible. Once free vesico-vaginal drainage is established, the purulent discharge rapidly resolves without further therapy. Orecklin and Goodwin (1974) have described the use of perineal vesicostomy as an alternative to cystectomy in the male patient with pyocystis but this procedure is as lengthy as cystectomy and requires diligent follow-up to ensure its patency. Finally the operation of prophylactic vagino-vesicostomy at the time of urinary diversion deserves discussion. Unlike cystectomy (as discussed) vagino-vesicostomy adds little operative time, operative risk or blood loss to a diversion procedure. However, by creating a large fistula between the bladder and the vagina the procedure is rather finite and makes the theoretical restoration to the status quo before diversion almost impossible. For this reason we have, to date, not used or advocated prophylactic vagino-vesicostomy and we know of no published series where this combination of operations has been tried. As the incidence of pyocystis following diversion in children is only 24% we feel, for psychological rather than strictly surgical reasons, that prophylactic vagino-vesicostomy is not a justifiable procedure. Summary 27 cases of pyocystis following ileal conduit urinary diversion are discussed. In those cases not responding to medical treatment, vagino-vesicostomy is recommended as an alternative to cystectomy.

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THE MANAGEMENT OF PYOCYSTIS

The operation of prophylactic vagino-vesicostomy a t the time of the original diversion is discussed.

References ECKSTEIN, H. B. and MOHINDRA, P. (1970). The defunctioned neurogenic bladder: a clinical study. In: Studies in Hydrocephalus and Spina Bifina. Developmental Medicine and Child Neurology Supplement, 22,46-50. ORECKLIN, J. R. and GOODWIN, W. E. (1974). Perineal vesicostomy: an alternative to cystectomy in male patients with a permanently defunctionalized bladder. Journal of Urology, 111, 151-153. RICHIE,J. P. (1974). Intestinal loop urinary diversion in children. Journal of Urology, 111, 687-689. SMITH, D. (1972). Follow up studies on IS0 ileal conduits in children. Journal of PcPdiafric Surgery, 7 , 1-10. SPENCE, H. M. and ALLEN,T. D. (1971). Vaginal vesicostomy for empyema of the defunctionalized bladder. Journal of Urology, 106,862-864.

The Authors Peter S. Stevens, MD, Registrar in Paediatric Surgery. Herbert B. Eckstein, MA, MD, MChir, FRCS, Consultant Paediatric Surgeon. Correspondence to: H. B. Eckstein, MA, MD, MChir, FRCS, Queen Mary’s Hospital for Children, Carshalton, Surrey.

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The management of pyocystis following ileal conduit urinary diversion in children.

27 cases of pyocystis following ileal conduit urinary diversion are discussed. In those cases not responding to medical treatment, vagino-vesicostomy ...
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